Inspection on 08/02/08 for Ashburnham Grove (75)

This inspection was carried out on 8th February 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashburnham Grove (75) 12/10/06

Ashburnham Grove (75) 25/04/05

Ashburnham Grove (75) 20/09/04

Ashburnham Grove (75) 05/05/04

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Edenvale

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Ashburnham Grove (75) 75 Ashburnham Grove Greenwich London SE10 8UJ Lead Inspector Ms Pauline Lambe Unannounced Inspection 8th February 2008 09:50 Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashburnham Grove (75) Address 75 Ashburnham Grove Greenwich London SE10 8UJ 020 8692 5032 020 8692 4301 michelle.capar@btconnect.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Greenwich Council Angela Margaret Gibbons Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Flats 1 and 2 are for residents who require long term care. Flat 3 is for residents who require respite care of no more than 6 weeks and one bed is retained for emergency admissions. 12th October 2006 Date of last inspection Brief Description of the Service: Ashburnham Grove is a registered care home for eleven younger adults with a learning disability, who are residents of the London Borough of Greenwich. The registered provider for the service is Greenwich Council. The home is situated in West Greenwich, within a conservation area known as the Ashburnham triangle. The home is close to the centre of Greenwich, the train station, Greenwich park and Maritime Museum. The service accommodates seven permanent residents within two flats, and four short-term or respite residents in a separate flat on the first floor. All the bedrooms are for single occupancy. The respite and long stay residents live on separate floors and each has a designated staff team. The property has a separate flat to the rear of the building, which residents use for leisure and activities. Greenwich Learning Disability pays the care fees with residents paying nominal fees for food, transport and rent. Residents pay privately for personal items such as toiletries and social outings. Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The site visit for this unannounced inspection was completed over two visits. The first visit was all day on 8th February 2008 and the second visit was on 20th February 2007. The manager, staff and where possible residents, participated with the inspection. Five residents was in the home in the morning on the first day of the inspection with others returning in the afternoon from the day centres. The home had six long stay and three respite residents at the time of this inspection. The service was last inspected on the 12th October 2006. The inspection included a review of information held on the service file, a tour of the premises and inspection of records, talking to residents and the staff team and reviewing compliance with previous requirements. The manager provided the Commission with a completed Annual Quality Assurance Assessment (AQAA), which provided information on the service and plans for future development. Feedback surveys were sent to residents and relatives prior to the inspection to obtain their views of the service. Feedback received from relatives showed satisfaction with the service and the quality of care provided. The manager and deputy worked well together to ensure the service was well run. Staff displayed a good understanding of the residents and their needs. One to one care was provided for residents when this was needed. Staff supported residents to have a lifestyle that suited them. What the service does well: What has improved since the last inspection? The service had a registered manager. Many area of the property had been redecorated and new furniture provided in the lounges in the respite flat and flat one. The homes policies and procedures had been reviewed. A system had been put in place to ensure hot water temperatures were monitored. Food temperatures were recorded. Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 6 Individual employee training records were introduced. The resident who occupied the separate flat had moved to a more suitable environment. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A satisfactory statement of purpose was available and residents were admitted to the home based on a full assessment of need. EVIDENCE: The statement of purpose for the service had been updated since the last inspection. A copy was sent to the Commission and it complied with regulation. One new long stay resident was admitted since the last inspection. The person was admitted as an emergency placement but has since been assessed as needing a permanent place. Residents were admitted to the service based an assessment of need completed by the community Learning disability Team (CLDT) and an assessment completed by staff from the service. Where possible new residents were given the opportunity to visit the home, have an overnight stay and get to know staff and residents before taking up permanent residence. Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans were person centred and reflected resident needs. Efforts were made to ensure residents were included in decisions made about care and lifestyle. Residents were supported to participate in all aspects of living based on risk assessment. EVIDENCE: Care records for two residents were viewed, one for a resident in flat 1 and one on a resident in the respite flat. Care records were very person centred and written in the first person. The records for the resident in flat 1 included an assessment of need, risk assessments and care plans. The care plan had been updated in January 2008 and reflected the needs of the resident. Risk assessments had been completed on arrears such as eating problems, using hot water, trips and falls and when going out of the home. The risk assessment provided adequate guidance for staff on how to manage risks. The care plans also provided adequate guidance for staff and included information on the resident’s skills and abilities as well as care needs and how staff Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 10 supported residents to be independent. Staff must take care to sign and date documents, as this had not always been done. Residents in flats 1 and 2 were unable to provide feedback on the service they received. Feedback received from relatives indicated satisfaction with the care provided. Comments made included “I am very pleased with my relative care” and “the young adults are well cared for”. CLDT and staff from the home assessed resident’s needs prior to their first admission to the respite unit. On subsequent admissions staff contacted carers’ or relatives to get an update on the resident’s state of health and well being. If this had not changed then care plans prepared previously were continued. If there had been changes to care needs then the person would be reassessed and care plans reviewed. Some respite residents stayed in the home regularly. Residents seen in the respite flat were very happy with the care they received and said they enjoyed their stays in the home. The property had no lift so residents with mobility problems could not be accommodated. Recommendation 1. Most of the residents in flats 1 and 2 were unable to fully participate in decision-making. Staff worked with relatives to ensure resident’s needs were met and appropriate decisions were made on their behalf. Staff also became familiar with the resident’s likes, dislikes, areas of interest and mood changes. This helped staff provide suitable activities, know when to use distraction methods and provide care in a way that suited the person. Residents in the respite flat were more able to make decisions and it was evident that staff supported and encouraged this. For example one resident was going out alone and the staff member discussed this with them and the boundaries in place for their safety. As previously mentioned risk assessments were in place in relation to safety, eating, participation in various activities and domestic skills. Restrictions to resident freedom were only made in the best interest and safety of the resident. Staff worked with relatives to ensure residents had opportunities for personal development and social opportunities based on risk assessment. Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were supported to take part in age appropriate activities and to access local facilities. Contact with relatives and friends was encouraged and menus seen showed a varied diet was provided. The kitchen in the respite flat required some maintenance work. EVIDENCE: Most of the residents attended day centres for some days of the week where they had opportunities for personal and social development. The day centre staff wrote reports on the person’s progress and involvement in various activities. There were no plans in place for the current residents to seek paid employment or to live independent lives. A ‘life planner’ was involved with preparing life plans for and with residents, which reflected progress made agreed goals for future development. Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 12 Residents were supported to take part in activities of choice and to access local facilities such as outings to the cinema, the pub, restaurants, hairdressing, local parks and to enjoy day trips and holidays. Staff worked with relatives to ensure they become familiar with residents choice and preferences and to have plans in place to meet these. Risk assessments were completed where needed in relation to activities and outings. As mentioned many relatives remained very involved with their resident’s life. Relatives said they were welcome to visit the home and where possible residents spent time at home with their family. Relatives said that staff kept them informed of issues regarding their resident and involved them in their care. One comment made included “there is always a warm welcome when visiting”. Residents had their meals provided in their allocated flat. The kitchens in flats 1 & 2 seen were clean and tidy. Adequate food supplies were seen and records were kept for the fridge, freezer temperatures and food temperatures. Staff prepared menus with resident involvement where possible. Menus seen showed a varied and nutritious diet was provided. Residents were encouraged and supported to assist with meal planning, food shopping, cooking, preparing tables for meals and clearing up. Foods with a shelf life once opened such as sauces and mayonnaise seen in all flat fridges had not been dated when opened. The kitchen on the respite flat was clean and tidy but required some maintenance work. The flooring was badly stained and areas of the work surface were damaged and no longer waterproof. Requirements 1 and 2. Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s personal and healthcare needs were met and recorded in their individual care plans. Improvements were needed to medicine management. EVIDENCE: Care plans seen showed how personal care needs were to be met. All bedrooms were for single occupancy, which provided privacy for residents. Staff were observed knocking on bedroom doors before entering and interacting in a patient and supportive way with residents. Personal care was given in private. It was difficult to assess this standard from residents view due to communication difficulties. Feedback from relatives did not indicate they had any concerns in relation to the element of this standard. All residents were registered with a GP and respite residents remained registered with their own GP when staying in the home. Arrangements were in place to ensure other health care needs such as dental, vision and chiropody services were available to residents. A private chiropody service was available if residents and relatives preferred this. Staff provided foot care for residents Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 14 where appropriate. Residents were supported to attend hospital and psychiatric appointments and reviews. A medicine policy and procedure was provided and was updated in March 2007. Medicines were stored separately for each flat. Medicine management was viewed for flat 1 and the respite flat. In flat 1 the medicines were stored in the staff office. The room was hot, 30C degrees on the day of the inspection and records seen showed that the room temperature was often at this level. Medicines were stored in a metal cabinet fixed to the wall. Boots supplied medicines in their monitored dose system together pre-printed administration charts. Staff recorded receipt of medicines on the administration chart but did not carry forward the amount in stock from the previous delivery therefore it was not possible to complete an audit trail for most medicines. It was also noted that there was overstocking of medicines in flat 1. Internal and external medicines were stored together in the medicine fridge and the fridge temperature was not monitored. In the respite flat medicines were stored in the staff office. The temperature of this unit was not monitored and staff said the room got very hot particularly in the Summer. A metal storage cabinet was provided to store medicines but was not fixed to the wall. It was not possible to complete an audit trail of medicines, as staff did not record the amount of medicines carried forward from the previous delivery. Internal and external medicines were stored together. In the respite flat a supply of pain relief medicines were seen for a resident but this medicine was not on the current administration chart. Hand written entries made on administration charts by staff did not reflect the details as written on the pharmacy label and had not been signed by two people. Records were kept for medicines returned to the pharmacy and staff had access to medicine information though this was not a recent publication. There was evidence to show that some staff had received medicine training since the last inspection. In view of concerns and lack of clarity around medicine management it was agreed to ask the Commission pharmacist to visit and inspect this standard to provide additional support and guidance for the manager. Requirement 3 and recommendation 2. Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate procedures were in place to manage complaints and safeguard adults. Relatives and residents indicated they knew how to make a complaint. Complaint investigations could not be assessed, as records were incomplete. EVIDENCE: A complaints policy and procedure was provided. Residents were provided with a copy of the procedure in a format with widget icons. Feedback from residents and relatives indicated they knew how to make a complaint and who to talk to if they had concerns. Seven complaints had been recorded since the last inspection however on viewing these four were incidents with residents and three were complaints. It was not possible to assess if complaints were managed in line with the service procedure, as none of the correspondence was available. It was noted that a neighbour had complained about the noise made by one resident. The manager said that plans were in place to fit double-glazing to the resident’s bedroom in an effort to resolve the problem. Requirement 4. A copy of Greenwich safeguarding adult procedure was provided. Allegations or suspicions of abuse were referred to the community learning disability team for investigation. Since the last inspection the local authority investigated one allegation of abuse and there was no evidence found to show that abuse had taken place. A second allegation of abuse was being investigated at the time of this inspection. Management and staff spoken with displayed an awareness of safeguarding adults and their responsibility to report this. Training records Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 16 seen showed that a number of staff had received training on adult protection since the last inspection. Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 27 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although staff and management had done a lot of work to improve the environment a number of issues were identified as requiring attention. The environment did not pose a risk to residents and residents and relatives did not raise concerns about the environment. EVIDENCE: Flat one had two bedrooms, a bathroom, lounge and a kitchen diner. The lounge and hall area had been redecorated, had laminate flooring fitted and new furniture provided. Two bedrooms were viewed and were clean, tidy and personal. In one bedroom the carpet was quite stained and in the other room there was an unpleasant odour. The manager said that new flooring had been ordered for both bedrooms and plans in place to redecorate both rooms. The bathroom was clean and tidy and hot water temperatures checked were within safe limits. Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 18 Flat two had five bedrooms and all were occupied. The flat had a lounge/diner, kitchen, bathroom, shower room and toilet. Two bedrooms were viewed and found to be clean, tidy and personal. The lounge was bright and tidy. The shower room was clean and homely but the flooring by the shower drain was split and was coming away from the wall behind the toilet pan. Hot water temperature checked was within safe limits. The respite flat on the first floor had four bedrooms. The flat had a lounge/diner, kitchen and bathroom. Three were occupied and plans in place to admit a fourth person. Since the last inspection the lounge had been redecorated, new furniture provided and all of the bedrooms and one bathroom and toilet had been repainted. The ceiling over the window in the bathroom was damaged and needed repair and painting. This issue was noted at the last inspection. Hot water temperature checked was within safe limits. A second bathroom, which staff said was not used, as it was not working properly, was cluttered with pieces of furniture and the door could not be closed. The kitchen was clean and tidy but the flooring was badly stained and some of the work surfaces were damaged, which meant they were no longer water resistant. The corridor in this flat needed painting and the carpet was badly stained and worn. Relative feedback included comments on the improvements made to the environment. Requirement 5. A domestic person was employed from Monday to Friday and care staff supported residents to help with domestic chores and personal laundry where practical. Hand washing facilities were provided appropriately. Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff were recruited in line with regulation and staff had access to appropriate training and regular supervision. Staff rosters had improved but did not include the employee’s full name. EVIDENCE: The staff team comprised of a full time manager and deputy manager, care assistants and domestic staff. Staffing levels were based on resident needs and occupancy of flats and the respite flat had a designated staff team. The night shift was covered with one waking person, one person sleeping in and on call back up cover for the service. The format for staff rosters had been changed, which made them easier to assess but they did not include the full name of staff on duty. The manager said that staffing levels were adequate to meet the needs of the residents. Ten of the nineteen care staff employed had NVQ2 qualification or above with four people currently working towards this qualification. Requirement 6. Employee recruitment files were not kept in the home and arrangements were made to view these at the second visit to complete this inspection. The Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 20 provider kept an employee information record in the home but his had not been reviewed for some time and did not provide evidence to show that recruitment had been completed in line with regulation. For example the form did not show if an application form was received, if there were any gaps in employment, if a reference had been obtained from the last employer if the post involved working with vulnerable people and did not show that references were verified as genuine if needed. If the provider wishes to continue using this form then it should be amended. Three employee files were seen and these did include all the information required by regulation. The manager had introduced individual training files for staff. Records seen showed that since the last inspection staff had access to training such as Mental Capacity Act, management of challenging behaviour, safeguarding adults, dementia care and autism. Staff also had access to mandatory training such as moving & handling, food hygiene and fire safety. Training records seen for three employees showed they had received three days training in the last year. Staff spoken with said they were satisfied with the training provided. A system was in place to provide staff supervision, which was undertaken by the manager and deputy manager. Records seen showed regular staff supervision was provided and staff confirmed this happened. Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Attention was given to ensuring safety for residents and others. Efforts were made to hold meetings with residents and involve them in making decisions about their lives and the service. There was no quality assurance system in place. EVIDENCE: The manager was in post for about a year and was currently managing a second service in the organisation. She had the skills and experience needed to fulfil her role and was supported by a full time deputy manager. Relatives contacted were satisfied with the way the service was managed overall. Long stay residents were unable to voice their opinion on this but residents seen on the respite unit knew the manager by name and indicated they were satisfied with the way the service was managed. Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 22 Residents meetings were held in each flat with efforts made to involve residents. A book was kept to record these sessions. Regulation 26 visits were made to the service and reports sent to the Commission occasionally. Staff meetings were held monthly where resident care and management issues were discussed. An annual satisfaction questionnaire was sent to relatives and other interested parties. The Commission received a copy of the findings of the survey but this did not include an action plan for improvement. There was little information in the AQAA about quality assurance and the service did not have a recognised quality assurance system in place. This is an area of management that requires improvement and development. Requirement 7. From the records seen attention was given to ensuring the health and safety of residents and others. Safety records checked included fire safety systems, gas certificate, electricity certificate, hot water temperature checks and the last environmental health report dated February 2007. Fire drills were held at times to include day and night staff and fire risk assessments had been completed for all flats. A system was in place to monitor the hot water outlet temperatures. Accidents to residents and staff were recorded and reported appropriately and notifications sent to the Commission as required by regulation 37. Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA17 Regulation 13 Requirement Timescale for action 04/04/08 2 YA17 23 3 YA20 13 The registered person must ensure foods with a shelf life are dated when opened and stored according to the manufacturers guidance. (Timescale of 27/11/06 was not met.) The registered person must 04/04/08 ensure the home is well maintained. The flooring and work surfaces in the kitchen on the respite unit must be replaced. The registered person must 21/03/08 ensure medicines are managed safely: Accurate records must be kept for all medicines in the home to enable an audit trail to be completed. Overstocking of medicines must be avoided. Internal and external medicines must be stored separately. Medicines must not be administered to residents unless there is a copy of the current prescription available. Two staff signatures must support hand written entries they make on administration DS0000036887.V353918.R01.S.doc Version 5.2 Ashburnham Grove (75) Page 25 4 YA22 17 5 YA24 23 charts and care taken to ensure the guidance recorded reflects that on the pharmacy label. The temperature of the rooms and fridges used to store medicines must be monitored. The registered person must ensure complaint records kept include a copy of the original complaint, evidence to show how the complaint was investigated and the outcome. The registered person must ensure the premises are kept in a good state of repair internally and externally: In flat one the bedrooms must be kept free of odours and carpets kept clean. In flat two the flooring in the shower room must be repaired. In the respite flat the corridor must be repainted, the carpet cleaned or replaced, the kitchen flooring replaced, the work surfaces in the kitchen replaced where needed and the ceiling in the bathroom repaired and painted. The registered person must ensure staff rosters include the full name and designation of staff and the hours they worked. (Timescale of 27/11/06 was not met.) The registered person must ensure that a system is in place to monitor and improve the quality of care provided in the home. (Timescale of 27/11/06 was not met.) 04/04/08 04/04/08 6 YA32 17 04/04/08 7 YA39 24 04/04/08 Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA20 Good Practice Recommendations The registered person should ensure all documentation is signed and dated. The registered person should ensure each resident has a medicine profile and staff responsible for managing medicines have their competency assessed annually. Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashburnham Grove (75) DS0000036887.V353918.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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